HOST: Madeleine Finlay

Guest: Dr. Jennifer Rohn, Head of the Centre for Urological Biology at University College Londo

Madeleine Finlay (1:14)

It can start with a suspicious twinge. An urgent need to pee. Tummy pain. Then comes the burn.

Anyone who’s had a urinary tract infection knows how agonizing they can be. Some infections go away on their own. Many need antibiotics.

Simple. Except beneath the surface of this very common infection, there’s a lot of mystery, unanswered questions, and unnecessary suffering. And it gets to the heart of the challenge of tackling antimicrobial resistance.

Carolyn (1:58)

Once you get a recurrent UTI, I’m afraid that the chances of getting another one are quite high. It’s almost as if you don’t clobber it the first time, it’s more likely to get entrenched and come back again and again.

Madeleine Finlay (2:12)

About 20 to 30% of all UTIs recur within about six months. But for some, they never go away.

Carolyn (2:21)

I literally kept a record of how often I was having to go to the loo, and it was eight times in an hour, every hour, every day. And of course, when that happens to you, you withdraw into your own world of pain.

Madeleine Finlay (2:37)

Chronic UTIs also present another problem. Often the infections don’t show up on tests.

Carolyn (2:45)

It was like being slapped in the face, first of all. And at the time, I was naive enough to think, well, the doctor’s know best. And if they’re telling me there’s no infection, then, okay, it must be something else.

Madeleine Finlay (3:00)

But as researchers learn more about the problem bacteria, they’re understanding why our current tests and treatments just aren’t up to scratch.

Jenny Rohn (3:10)

You know, I know it’s a terrifying and awful thing, but it’s also really fascinating, and I have a lot of respect for the bacteria because they are tiny, tiny little things. They’re two microns. They’re tiny little things, and they can bring people to their knees.

And they have so many ways to outmaneuver us.

Madeleine Finlay (3:29)

So today, we’re asking, what’s the latest understanding of UTIs? What’s happening when someone gets a chronic infection? And is there anything on the horizon that could help flush an infection without contributing to our overuse of antibiotics?

From The Guardian, I’m Madeleine Finlay, and this is Science Weekly.

Dr. Jenny Rohn, you’re head of the Center for Urological Biology at University College London. First of all, can you explain what a UTI is and who’s most at risk of one?

Jenny Rohn (4:10)

A UTI is simply an infection of the urinary tract, which is basically your waterworks. That can be your kidney, your bladder, your urethra, which is the little tube that connects the bladder to the outside world. But usually when you hear the term UTI, you’re talking about a bladder infection.

And these are caused by bacteria. There are a lot of bacteria living in your back passage, as we all know. Most of them are friendly, but some of them are not friendly.

And they can, in certain situations, can migrate into the urethra and then up into the bladder and cause problems. And although anyone can get a UTI, it is most common in women, probably because of the anatomy. So our back passage is much closer to the urethra than a man’s back passage.

It can also be very common in children and also in the elderly, things start to equalize a bit and men start getting UTI as much as women. But by and large, this is a disease of women and about one in two women will get one in their lifetime.

Madeleine Finlay (5:04)

Right, so bacteria that migrate from the back passage to the urethra can cause a UTI. But how exactly does that happen? And how does an infection then take hold?

Jenny Rohn (5:16)

So they get up there, they climb up through the urethra and end up in the bladder. So there’s lots and lots of urine and the urine is flowing the wrong direction. It’s trying to wash out all the bacteria.

But these uropathogens or bacteria that cause UTI have all sorts of tricks in order to cling in in this inhospitable environment. So they have sticky appendages that help them to latch on to the bladder wall despite the urination. And they also have ways of hiding from the immune system and from antibiotics.

Two of these ways are, one, they can actually burrow into the bladder wall, which is kind of horrific to think about. So they actually dive into your cells and take up residence inside them. Well, it’s nice and cozy.

There’s plenty of nutrients in there. There’s no antibiotics. There’s no immune system.

Another thing that bacteria can do is they can form these slimy communities known as biofilms on the inside of the bladder wall. And these were also very resistant to antibiotics in the immune system. Those are two that I’ve mentioned, but there are dozens and dozens of strategies they have to get around our defenses and our drugs.

Madeleine Finlay (6:22)

It’s so impressive. And I wonder, once you’ve got this UTI, how do they tend to be diagnosed and how accurate is a diagnosis? How easy is it to pick up that somebody has got a UTI?

Jenny Rohn (6:35)

Diagnosis is definitely a problem. If you have a really raging UTI, you don’t really need diagnosis. You’ll be well aware if you’ve had one that it’s obvious, right?

Your urine is full of cloudy pus, often blood. You’ve got terrible pain when you urinate. Nevertheless, the GP still wants to see some evidence that you’ve got a UTI.

And so what normally happens is you get a dipstick, a little piece of paper is dipped into your urine and it changes color if you’ve got a UTI in theory. And then if it looks like you’ve got a UTI based on the dipstick, they’ll send your urine off for a midstream culture. They try to grow bacteria from your urine.

Now both of these techniques are a little bit flawed and they’re very old fashioned. I want to point out that the midstream urine culture was pretty much invented by Alexander Fleming in the 1920s and things like the dipstick, they don’t work very well. They’re very insensitive.

So imagine you’ve got an infection and a lot of the bugs are actually hiding in biofilms or hiding in your bladder wall. Then the bugs won’t be in your urine or they’ll be in your urine at a very low level. So these tests often fail to pick up a bone a feed a UTI.

It’s kind of like tossing a coin, whether you’re going to test positive for UTI, if you have maybe a lower grade infection that wouldn’t show up in these very old fashioned tests.

Madeleine Finlay (7:51)

A 2017 study found that UTI diagnostic tests gave the wrong result in at least a fifth of cases. For people with chronic UTIs, infections that don’t go away after a typical course of antibiotics, this can be a real problem and make diagnosis very hard. As Carolyn found, she was on a trip up to Scotland in 2015 when she was hit with an initial infection.

Carolyn (8:19)

We got as far as Berwick-on-Tweed, and I suddenly thought, God, I’ve got UTI, how weird, come out of nowhere. And it got worse and worse, and by the time we got up to Edinburgh, I was rushing to the loo, I was in pain, saw a GP there, and I got a call two or three days later to say the test had showed negative, there was no infection, which was really strange.

Madeleine Finlay (8:42)

When her first course of antibiotics didn’t clear the infection, she went back to her GP at home for more tests.

Carolyn (8:48)

My own GP could not identify a UTI. The test kept coming back saying nothing abnormal discovered or contaminated, simply nothing. I was starting to think I was going mad, inventing it all in my head.

Madeleine Finlay (9:05)

So while the tests weren’t picking up Carolyn’s infection, she had to suffer through months and months of living with an unabated UTI.

Carolyn (9:15)

Obviously at that point, you’re thinking, well, how am I going to live like this? You know, I love to go to the theater, I love to do all sorts of things. I couldn’t go anywhere.

Your sex life is an impossibility, like if you’re in that much pain. My life had become so tiny. When you don’t know if you’re going to get any better, it is just horrific.

And depression kicks in. My greatest salvation was finding a group that I could work with and talk to of other women who had similar things. And we’d have lunch in a local pub and everybody would talk about it and help each other.

Madeleine Finlay (9:53)

Then Carolyn found Professor James Malone Lee, who was pioneering research and treatment for chronic UTIs, including the long-term use of antibiotics.

Carolyn (10:04)

I was on antibiotics for three and a half years and gradually, gradually, my symptoms started to get better and I started to have the odd good day.

Madeleine Finlay (10:16)

Today, Carolyn is UTI-free. But despite her success, the long-term use of antibiotics is a fine balance. It doesn’t come without side effects and the risk of antimicrobial resistance.

Currently, the guidelines state that men should be prescribed five to seven days of antibiotics, whereas women are typically given a three-day course. Campaigners like Carolyn argue that this often isn’t enough to clobber that initial infection and prevent UTIs coming back. But if we don’t tackle antimicrobial resistance, we won’t have anything to treat UTIs with.

Back to Jenny.

Jenny Rohn (10:57)

Antimicrobial resistance has been on the rise for the past century. The number one resistant bug at the moment, according to the WHO and a few other studies, is E coli. So E coli is the most common UTI bug.

It’s also the one that’s the most resistant. It’s really a problem. So the more antibiotics humans take and animals, the more drugs are out there in the environment, in the water supply, in the soil.

And then every time a bacteria encounters an antibiotic, those that can resist will survive and those that will die will die. So that just selects, kind of evolutionarily, for a bacteria that are resistant. And then they love spreading these resistance genes around.

They spread on little things called plasmids, little bits of DNA and they’re like business cards. The bacteria can pass them from one to the next, say, hey, I’ve got this really useful bit that allows me to resist penicillin. Would you like it?

If you don’t do something about it, pretty soon we’ll be back to an era where you can’t have an operation, even a routine operation because it will be too risky.

Madeleine Finlay (11:53)

That’s obviously terrifying. So is there anything else that can help treat UTIs or other non-antibiotic treatment options that are on the horizon?

Jenny Rohn (12:04)

There are some pretty good studies with D-mannose. D-mannose is a sugar you can buy over the counter. It prevents certain bacteria from binding to the bladder wall.

It’s got some pretty good data. There’s a little bit of controversy. And equally, cranberry extract.

Again, people go back and forth about whether this is useful, but by and large, the study suggests that it can help a little bit. But these are very sort of modest weapons against UTI. I would consider using them, but they’re not gonna be as good as antibiotics when antibiotics work.

As far as the future, there are a few things on the horizon, disappointingly few, I would say. This whole area has been neglected for decades. There isn’t a lot of research.

There isn’t a lot of drug development, most likely because it’s a women’s disease. People aren’t interested in it, and it’s not necessarily gonna be a blockbuster drug. And maybe there’s no profit margin in it.

But there’s a few things on the line. There’s an interesting new vaccine called Urimune, which has been reporting some excellent findings. I should also mention probiotics.

People are looking at using our good bacteria to fight the bad bacteria. And I think that’s a very promising strategy.

Madeleine Finlay (13:06)

Jenny, this infection is so common. It affects 400 million people every year worldwide. And yet we’re nowhere near the kinds of tests and treatments that we need.

What needs to happen, do you think?

Jenny Rohn (13:21)

This would all start with awareness that it is a serious problem. We need better education at the medical school curriculum. So I teach medical students as my job as a professor and most of them have absolutely no idea that UTI is a complex disease.

In the textbooks, you know, all is well. It’s just a, it’s a trivial disease. You know, you diagnose it this way and you treat it this way.

The students have no idea.

Madeleine Finlay (13:46)

This lack of knowledge around UTIs and chronic infections, not just amongst medical students, but doctors and even sufferers, was something Carolyn and her support group were keen to tackle themselves.

Carolyn (13:59)

We set up a not-for-profit company called Chronic Urinary Tract Infection Campaign, CUTIC. What we’d really like is to see the women’s health strategy expanded to include chronic UTI. And if we get a change of government, we would like the new health minister, whoever that’s going to be, to actually take notice of chronic UTI and be prepared to talk to us and the specialist doctors to have a look at how we can get to the bottom of this disease.

In five years from 2018 to 2023, there have been over 1.8 million admissions for UTI. And these are NHS England’s own statistics. And the NHS mortality rate for UTI is 4%.

So four people in every hundred will die of UTI. And chronic UTI is still not taken seriously.

Madeleine Finlay (14:59)

Finally, Jenny, what advice would you give to maybe somebody listening today who might want to protect themselves from a UTI or perhaps thinks that they have a UTI but isn’t getting the treatment that they feel they need?

Jenny Rohn (15:14)

Well, protection from UTI, there’s no simple answer, but it is widely understood that you do need to have good hygiene. Of course, if you produce feces, you should wipe from front to back. People say it’s useful to urinate before and after sex, and you can understand why, because you can sort of flush out the waterworks.

Drinking lots of water is important. The more you urinate, the more you’ll be facilitating that natural flushing process. Don’t hold your urine in, because it’s known that retaining urine will then set up a situation where you’re sort of fermenting the urine in there.

It should be being flushed out constantly. So don’t hold your urine. As far as if you think you have a UTI, and you’re not sure, and you go to your GP and they fob you off, say, listen, I’ve got these symptoms.

I know that the diagnostic tests are a little bit insensitive. I would like to insist on a second opinion, or I would like you to take the test again. And if the tests come back negative, I’d like to have a course of antibiotics.

And if then it clears up, I know that I had one. I don’t know how successful you’ll be because of antimicrobial resistance. Most GPs are under orders not to give unnecessary antibiotics.

So you might have a fight on your hands. But I know a lot of patients are successful just by advocating for themselves and being quite verbal. So maybe don’t take no for an answer.

Madeleine Finlay (16:36)

A big thanks to Dr Jenny Rohn and to Carolyn. You can find out more about Carolyn’s campaign, CUTIC, at cutic.co.uk. And we’ve put a link to that in the show description.

And if you’ve been following our General Election coverage on the Politics Weekly podcast, you might have noticed that you haven’t heard from our political editor Pippa Crearer and correspondent Kieran Stacey yet this week. Well, they’ve been busy on the campaign trail and they’re going to be back on Thursday with all their insight and a late night analysis of the twists and turns of the last TV debate before the election. So just search for Politics Weekly UK wherever you listen to your podcasts.

And that’s it for today. This episode was produced by me, Madeleine Finlay and Holly Fisher. It was sound designed by Joel Cox and the executive producer is Ellie Beurie.

We’ll be back on Thursday. See you then!